Tuesday, January 31, 2012

My physician says I should eat a little aspirin every day, to keep the heart attacks away. She says I should do a few other things too, and I occasionally do some of these. But not every day. A little aspirin a day is easy, and it doesn’t mean I have to give up any of the good things I don’t wish to give up. But I take aspirin so my blood won’t clot so easily, for that is how you avoid some of those heart attacks. And that means I bleed something awful when I get bit or scratched. Like today.

One of the nice things about being a veterinarian is I have all the bandaging materials I might ever need, right there in the treatment room of my clinic. So when I do get ripped up in the course of staggering through an average day, and I need a big bandage for my arm, for instance, I just open the cabinet. As I sit here in my recliner chair, watching some drivel on the evening tube, I have a nice bandage on my arm, from my wrist up to almost the elbow. Keeps the blood off the furniture, and my better half appreciates that. And soon I will have another scar to add to the railroad map that is my forearms.

You might wonder how I managed to survive the tiger ambush, or the Rottweiler chomp. Was that an attack trained German shepherd, or a psycho Doberman that hunted me down? Or just perhaps a pack of rabid chimpanzees? Nope. Actually, my attacker was one of those beasts we veterinarians lovingly refer to as a “land shark”. Yep, it were one of those nasty evil things.

It was a Chihuahua.

A mix actually. One of those midget beasts of uncertain parentage that are all the rage these days, thanks to the tiny mutants that fill the purses of so many actresses and actors in the pages of the tabloids you read in line at the grocery store. This guy was all of seven or eight pounds, hardly an imposing monster. But you know what they say about “it ain’t the size of the dog in the fight; it’s the size of the fight in the dog”? Well, this little devil had his share of that fight in him.

The medical chart gave a hint to what lay ahead. New client. Puppy has had no vaccines. Age of puppy…unknown. I wandered out to the dog waiting room to fetch him in. He was a mostly grown 7 month old teenager of a dog.

Three generations of humans filled the room. The little doggie was on the floor, leash trailing behind him, with not a hint of a human hand on the other end. The snarling little darling came halfway across the room toward me as I entered, all growlbarkteeth. When the tail goes up and he stares right into your soul, he means business. And not one of those eight people made any attempt to control the dog, or correct his behavior. Great. Here we go again.

Been here before, you see. Don’t know when it happened, but it is now illegal to use the word no when you live with a land shark. You don’t want to hurt their feelings. You don’t want to break their spirit. And when the (you have to forgive me here, because you remember how when you were sixteen, and you saw an adult over, say, 25 years old, you couldn’t tell whether you were looking at a person of 25 or 60? Well, when you are my age, and the girl children dress like hookers and have breast implants and liposuction before they are fourteen, and you can’t tell if they are 13 or 35, it’s kinda hard to age some of them) young woman reaches out to hug the charming little dog into her bounteous bosoms, all those years of experience doctoring pets will tell you that this dog is going to be JUST a BIT spoiled. Because it’s that young woman’s first born.

We adjourn to the exam room, and the young woman places the dog on the table, and immediately unhooks his leash. And she turns and walks away. And the little dog air launches. My life goes into slow motion at that point. Visions of broken legs, busted teeth, bloody noses as I await the inevitable splat when he reaches the floor. The sound of his landing is chilling, but somehow he survives the equivalent of you or I popping out of a sixth story window. She laughs (?) and then plops him back on the table.

Now, I’ve played this game before. In fact I’ve played this game for decades, so I know that land sharks are generally fear motivated. They often have only lived with a few people, so everyone else is a stranger. They often live with men that follow the old rules that mandate kicking the dog after you’ve kicked the wife and kiddies, so I expect a land shark to hate men. They often have never left home, much less set foot upon mother earth, so anyplace else is an alien place to them. So I try all the tricks to put them at ease.

First, I try to put their people at ease, for if their people hate or fear mendoctorsmenvetsmen, the dogs will pick this up right away, and they’ll go all psycho on you. So I’m friendly, soft body language, baby talk the dog, high in the voice register, and don’t look the dog in the eye nice guy. Don’t approach the dog right away. Let everybody grow accustomed to the room. Tell a joke or six. Let the little beast smell the back of your hand. Pet em for a month or so before you begin any exam. You know, the usual tricks. Sometimes this works wonders.

But not today. Every single thing I try nets only growls and teeth. Fine. Sometimes the dog lays down the rules for the engagement. Well, I have my rules, too.

I expect to get to the end of the day with six fingers on each hand. This is not negotiable. OK five. Just wanted to see if you are paying attention. Two times five fingers is important, for if I run out of fingers I have to become a politician or something just to make a living. And I’d hate that. But I sure couldn’t do this work anymore, and I like this work.

So I slip my own lead around the little dog’s neck. This gives me a semblance of control of the dog without sacrificing any fingers. It gives me one last chance to pet the dog safely without exposing fingers to unnecessary risk. Sometimes this works.

But not today. The dog doesn’t like my leash. Soon I am playing him like a bass on light tackle. He pulls this way, I urge him back that way. He bites the leash. It’s not my finger. His young woman runs in tears from the room. The brilliant notion enters my head….Send the little dog home right now. Go home myself and have a drink and watch reruns of MASH. Save fingers and bloodpressure.

But no, I figure I can get him vaccinated and send him on his way and no one need get hurt, and with the young lady out of the room, there’s that much less drama to sweep up later. So I grab him by the scruff of his neck, and we tie his mouth shut and I do my exam and vaccinate him, and like always, he never even feels the injections. Everything is peachy.

Oh sure, the little dog did bit my tech as she tied his mouth, but he didn’t break the skin. And that blood all over the table is mine, from that 8 inch long incision he made in my forearm with a hind foot claw. But that’s just the dang aspirin.

Just another day in the trenches. And it’s over with no fatalities. Until the boyfriend opens his attitude.

Boyfriend doesn’t like how I handled his dog.

Ah, you have a very poorly behaving dog.

I choked his dog.

Ah, no. I know how to choke a dog. That wasn’t it. That was holding the biting end so no one was seriously injured by your dog. Well, you get paid to get bit. Ah, no. I get paid to try to help you, in spite of the fact that it is your fault that the dog is so poorly trained and socialized that he has become dangerous.

He never acts that way around us!

Well no, cause you have never made him do anything he didn’t want to do. What you just witnessed here was your dog attacking me because I tried to pet him. That is simply wrong. What you have here is a dog so dangerous that if he ever gets seriously sick, he is gonna die because no one will be able to treat him. He needs training now if it isn’t already too late.

Oh, and he needs a new veterinarian, for I will not see him again. And that too is your fault.

I work with poorly behaved dogs every day, but I have two rules that must be followed for me to do this.

Number one: you don’t laugh when your dog tries to hurt us. That should be self-explanatory.

Number two: you don’t blame me for your dog’s bad behavior. You apologize for your dog’s bad behavior. That would be polite.

I’m good at this, and I’m here to help your dog. I don’t get paid for YOU to let YOUR dog injure me or my people.

Apparently this video of a dog helping out at the front desk at a veterinary hospital is stirring up some controversy. Some people think it's gross to have a receipt handed to them by a dog. Personally, I think those people should avoid my hospital. But I'm curious what the general readership thinks! Check it out here.

We at VBB central typically share the heartbreaking cases where a beloved pet suffers due to owner misbehavior, poor choices, etc. Here's one where everything worked out, courtesy of one of our readers and her personal pet:

One Saturday afternoon I got a call from an rDVM that he was sending a 10 week old Boxer with white gums and a hematoma on his head over to my e-clinic. When he got to us he was indeed white and had a couple of spots of bruising. I questioned the client and after she made a phone call we found out the puppy had been in a room with rat bait the day before. I worked up an estimate for hospitalization, blood work, supportive care and a transfusion of plasma as well as packed RBC's (my e-clinic does not stock whole blood). The total came out to around $1500. The client was devastated and told me she couldn't afford treatment. I happened to have brought my 5 year old standard Aussie to work with me that day to have him shaved down for the summer by our groomer. So after pondering what I could do about the bill (I'm just an associate, I don't set prices and can't make much in the way of executive decisions), I offered her an alternative. I said if she could pay for hospitalization, a few medications, and the transfusion set I would bleed my own dog to donate blood for her. She spent the next hour calling friends and family to help with the bill (it came to around $600) while we sedated my dog and collected 400mls of blood from him. Boomer the boxer did smashing. He went home the next day acting like a normal bouncy puppy with 6 weeks worth of vitamin K. I told the 8 year old little girl that hugged him at pick up that she better take good care of him because he now had a little piece of my aussie in him.

Monday, January 30, 2012

I hope it doesn't increase the number of break-ins at veterinary clinics. I think I'll go reinforce the - hey! Gotta go. There's a horde of depressed people heading up our driveway! AAAAAAaaarrrgggghhh!

These days, everyone is special, right? Awards ceremonies for children's activities have become nearly meaningless, because EVERYONE gets an award. Even my own kids have told me they think it's a complete waste of time and stupid, and that no one ever gets to feel special, because the people in charge are always saying how special everyone is. But for some reason, some people really like that feeling of being somehow special, so much that they project it onto their pet. Not just their pet, actually - their entire breed.

Now, don't get me wrong. It's true that each breed of dog or cat or horse or sheep or whatever has its own set of interesting qualities that set it apart from the other breeds of dogs or cats or horses or sheep or whatever - otherwise, they wouldn't be separate breeds. And obviously, some people will prefer one type over another type, and that's great. What really drives me nuts though is the people who make this big fuss over how SPECIAL their breed is when it comes to: anesthesia, vaccines, antibiotics, parasites, or other medical issues. Because 99% of the time, it's complete bullshit. Seriously.

When is it NOT complete bullshit? Well, ok, Greyhounds. Greyhounds sometimes develop perioperative hyperthermia, possibly related to anxiety. Greyhounds and similarly very lean sighthounds used to have bigger issues with general anesthesia when the main drugs used were injectable barbiturates. So, if you walk into my clinic and you have a greyhound who needs general anesthesia, and you say "Oh, doctor, I just can't allow that, Greyhounds are special and they can't be anesthetized, how could you not know?" I am going to mentally *headdesk* while I bite my tongue, and then I will take a deep breath and smile and explain the GREAT NEWS that we have actually advanced quite a bit beyond the injectable barbiturates that used to be such a problem, and that we have new and better balanced anesthesia protocols these days, and we can use anxiolytics to manage the perioperative stress, and honestly, you don't need to panic. Hopefully, you'll be pleased to have learned this, and we can proceed.

There are also a few other breed-related laboratory idiosyncrasies that sometimes come up, and of course there are different inherited disease and so forth, but honestly, this "special" business is something else.

Examples of some of the complete bullshit I have heard:

1. "My puppy can NOT have a leptospirosis vaccine. My breeder has been breeding MaltiFlufferPoos for 25 years, and she knows. Lepto vaccine will KILL my puppy and I refuse to allow it. This breed is just very sensitive to the vaccine and when you give it to them they swell up and get bloody diarrhea and die." I will mentally translate this to "my breeder once had a puppy experience anaphylaxis, freaked out, and refused to ever give the vaccine again. Hey, maybe if she's really high volume, it happened twice." I will try to explain to you that there is no one particular breed that DIES from lepto vaccines more than any other, but most of the time people with this idea drummed into their heads won't listen to me. Also, FYI: MaltiFlufferPoo is not a breed.

2. "I refuse to allow you to give any deworming medication to my puppy. The breeder told me that Garbage Hounds are very special in that they react badly to all dewormers, and we need to let him develop his own immunity to the worms." I have no reasonable explanation for this. Maybe the breeder had a bad experience deworming a group of puppies one time? I have a hard time believing that, most common dewormers have a wide safety margin. I find it extremely frustrating, especially when there are children in the home who might be at risk for developing a larval migrans syndrome.

3. "My dog is not just a small dog like all the other small dogs you see routinely. He is a very special nano-teacup miniature micro yorkie. He has to get only 1/4 the dose of all vaccines." No, sorry. The immune system does not work that way. The dose of vaccine is not up for debate. We are giving the entire vaccine, or we are not vaccinating your dog here today. Also, there is no such thing as a nano-teacup miniature micro yorkie. I don't care if you paid $3500 for it, it's not a real thing. By the way, since we're on the subject, I know you said the breeder told you it's normal, but - hydrocephalus is actually not normal and your puppy looks like a conehead.

4. "Doctor, my kitten is a Bengal. You may not know this but they are very special cats. They require a 70% as fed protein diet made up of mostly raw meats." Hate to break it to you, but no, the nutritional requirements of the Bengal is not markedly different from the nutritional requirements of other domestic feline housepets.

5. "My Devon Rex is non-allergenic." No it isn't. While there is some variation in amount of dander that a pet leaves lying around and of course the volume of hair falling off it will play a role, an allergic individual may still react to your cat, because it is a cat, and it has a salivary protein called FelD1, and it grooms itself, and that stuff dries on there, and then flakes off into the environment. FelD1 levels can vary per individual cat and on a population level some breeds may make more than others but there are no standard breeds of cats that do not have any. Sorry.

Sunday, January 29, 2012

While I realize that sometimes we *do* get hung up on being negative, I wanted to post my own story about my recent acquisition of a new puppy. :)

A little history: I lost the doggy love of my life last July. July 26th to be exact. I had him with me for 15 years and saw him through his hyperactive younger years, his graceful middle-aged years, his old age. We went through vet school together, divorce together, moved across the country a couple of times together, changed jobs and changed lives together. He was my buddy and the day I lost him was honestly one of the worst days of my life. I saw him through cuts and bruises, bad teeth, glaucoma then blindness, deafness and finally, doggy alzheimers that was so bad I couldn't stand to see him live like that any more. So I made the gut wrenching decision to let him go when I realized I was holding onto him more for me than for him.

It was just like it is for my clients on a daily basis. I help them through the same decisions and I try to give them comfort in knowing they aren't alone, that even Ihad to make this decision about the absolutely doggy love of my life also.

So it took me about 6 months before I could even think about even looking for another dog. I knew I'd adopt one (cause I don't do the whole paying-for-a-dog thing other than adoption fees) but didn't know who or when.

I started looking through the websites and finally found, after looking at about 1000 pictures, a little face looking back at me that immediately stole my heart. I had to believe that there was a reason behind it, so even though I wasn't sure if I was ready or not, I contacted the rescue.

Of course they sent me all sorts of pictures of him and each one was cuter than the last. I decided to try to foster him for a few weeks to see how he'd work out.

Yeah. Right.

The rescue delivered him to me and it took about 1 second for me to look at his little face to know he was mine. There would be no fostering. He was home. And now I'm loving waking up in the morning to a little wild child who gets into trouble, climbs on things and brings me my dirty socks and hides his milk bones under my husband's pillow. And when he jumps up and licks my face I cannot help but to fall even more in love with him.

I'm writing this one to let people know that while some out there think we are heartless, it couldn't be farther from the truth. We are loving, caring, generous and extremely humble and love our animals just as much as our clients.

Friday, January 27, 2012

Saw a puppy today for a post-purchase exam. For those of you who aren't familiar with the term, it's where the proud new puppy owner presents us with the breeder's list of absurd recommendations, and expects us to state categorically, on the basis of a physical exam, that the animal is completely healthy and has no genetic or congenital defects. This gets the breeder off the hook if a hidden problem (that couldn't be detected on physical examination anyway) arises later in the pet's life.

Anyway, I pointed out to the owner that both of the puppy's testicles were descended. He said that was fine, since they were planning on neutering him anyway. I explained that it was actually an important finding, because neutering a puppy who is an abdominal cryptorchid is a lot more involved than a routine prescrotal orchiectomy. In fact, I explained, it's a whole different...BALL GAME! HA! As usual, his only response was a blank stare of incomprehension. No one in my practice seems to appreciate my sense of humor.

Almost all the veterinarians I know carry professional liability insurance through the AVMA's Professional Liability Insurance Trust. Yes, I said *almost,* so, calm down, you crazy cowboys out there (you know who you are). To keep their insured members aware of what types of things veterinarians get sued for, they publish a newsletter a few times a year in which they describe interesting cases in which a veterinarian got sued for something and was either found liable or not liable for the client's loss.

I'm going to take a moment here and just mention something unrelated to the major point of this article. The fact is, in the USA right now, in most jurisdictions, pet dogs and cats are valued as property (this may be changing, as a recent ruling in Texas ascribed "special value" to pets, but for now, it's generally true). This limits the liability of the veterinarian, in general, and makes our liability insurance much more affordable compared to that of, say, an OB/GYN, or your favorite neurologist. This is nice for veterinarians, and helps us to keep our costs down. If or when the legal climate changes, and pet owners become more likely to win larger judgements against veterinarians, insurance costs will rise, and veterinary costs will rise, and pets will get less care because people won't be able to afford it. But that should all be covered in a separate and much more depressing blog post than this is intended to be.

Moving on.

So some time last year, I read a case in one of these PLIT newsletters about "Dr. B."

Basically, someone brought their cat to Dr. B for a routine exam and vaccines. The owner helped the tech weigh the cat, and when the cat got off the scale, the owner thought it might be falling and moved to redirect it. The cat at that time bit and scratched the owner's hand. The technician cleaned and wrapped the hand for the owner, and Dr. B told the owner to seek medical care from a physician. The owner then left with the cat. Within 24 hours, the owner’s hand became infected, and it failed to respond to treatment quickly. At that time the owner called Dr. B and requested Dr. B pay for out-of-pocket medical expenses. Dr. B reported this to PLIT and consented to settle; claim review was performed, and it was determined that it was BELOW THE STANDARD OF CARE TO LET THE OWNER ASSIST WITH HANDLING THE CAT DURING THE EXAM, and they recommended settlement. Long story short, this ballooned into a big deal because the owner's hand was very badly injured and needed to have multiple specialists involved and trips to the ER and home nursing care and so on. In the end, PLIT paid over $22,000 to the cat owner (and the cat owner's health insurance company, which had pursued subrogation) to close the claims.

"OK, well, that sucks for them," you might be saying right about now. "Why are you telling me this story, Dr. VBB? And why is that bit about the owner assisting being below the standard of care in bold all-caps, anyway?" you inquire. Well, I'll tell you why. This concept of owner handling and/or restraint of the pet during a veterinary office call comes up every day in my office. It is the rare client who willingly lets go of his or her pet and allows my staff to restrain it! Every day in my office we have something like this happen:

Me: [walks into room. owner is holding pet in arms or on lap.] Hi there! Good to see you! Can you put Fluffy on the table for me?

Client: Sure [puts pet on table]

Me: OK, I'm going to examine Fluffy now. You can talk to him and stand where he can see you though. [I'm starting my exam]

Client: [keeps death grip on Fluffy, who looks very suspicious of the entire scenario]

Me: Actually I'm going to need you to let go of Fluffy for the moment, ok? I might startle him and he could lash out at you and you could get hurt. [I'm continuing my exam]

Client: Oh, Fluffy would NEVER do that! He loves me! [squeezes pet close to chest/face and grins, pet lifts lip and snarls]

Me: OK well I'm going to move Fluffy over for a moment so I can listen to his heart [put stethoscope on pet's chest, try to keep out of reach of teeth]

Client: Fluffy is SO GOOD [pats pet's chest rhythmically] oh and doctor I wanted to tell you this really important thing

Me: [stops ausculting] what? sorry, I was trying to listen to his heart. and please don't pat him while I'm doing this ok? It makes a lot of noise.

Client: But Fluffy will be scared if I'm not here! [maintains death grip]

Me: Actually lots of pets calm down when their anxious owner steps out, so if you want to leave that's fine, but you can stay too, I just need my nurse do the actual restraint.

Client: Don't wanna.

Me: Sorry?

Client: How dare you say I can't hold my own pet! It's an outrage!

Me: Well, you know, if Fluffy is surprised or hurt, he might bite, and if you get hurt-

Client: I don't mind if he hurts me!

Me: That's good to know, I mind if you get hurt, and also if he hurts you during this exam in my exam room, it's a big liability and I will be the one who did not reach the standard of care, which requires me to provide adequate restraint by a staff member in order to protect you from injury.

Client: well I would never sue you

Me: I'm sure you wouldn't, but I still need to reach the standard of care here....

and then either they laugh it off and agree with me and we go ahead, or they get really pissed and claim I am some horrible person who only cares about legal technicalities and not animals.

Thursday, January 26, 2012

VBB's Receptionist: Hello, World's Best Veterinary Hospital, how may I help you?
Client: My cat is dying. What should I do with the body if she dies while you're closed?
VBB's R: Hold on. What's going on with your cat? Do you want her to see the doctor?
Client: No, I don't want to pay for a visit. I just want her to die at home but then I don't know what to do with her body when she dies. Is there someone who will come get it?
VBB's R: We can see her today. Do you want to come in today?
Client: No, I just think she's dying. Please tell me what to do with the body.
VBB's R: Well, you can wrap her in trashbags and keep her in the freezer or garage until we open and then bring her to us for cremation if you like. But are you sure you don't want to have her see the doctor, even for euthanasia?
Client: No. I said I want to let her die at home!
VBB's R: Ok, I'm sorry. I'm sorry your cat is sick. Take care.

Friday morning:
Ring! Ring!

VBB's R: Hello, World's Best Veterinary Hospital, how may I help you?
Same Client: It's my cat! she's having trouble breathing. I'm on my way in with her.
VBB's R: Wait. Is this the cat that was supposed to be dying at home?
Client: Yes, but, I didn't think she was going to have trouble breathing! She can't live like this!
VBB's R: Well, no. When an animal dies, it stops breathing, and stops living. So, you're coming in?
Client: Yes, of course, I'll be there soon. [hangs up]

The client and her poor cat did arrive shortly after, and the cat was in fact having trouble breathing. The owner wanted us to fix the breathing so that she could take the cat home to die - but wanted to make sure the cat wouldn't continue to have episodes of trouble breathing. On the one hand - I do understand it is horrible to watch someone you love struggle to breathe. I have watched countless animals as well as a couple of humans do this, and it is just awful. On the other hand, like my receptionist said - when you die, you do stop breathing. Sometimes, when you're in the process of dying, you breathe irregularly for a while, and then do some gasping, because of the way CO2 builds up and triggers a reflex to breathe. Death is not like a Hollywood movie.

We ended up euthanizing the poor kitty because I could not promise that there would be no additional episodes of dyspnea. I hope the client wasn't too disappointed that her kitty didn't get to die at home.

I started my practice doing house calls full time. The pets are often less stressed and clients treat you like a guest in their home. I really got to know these people well in this setting and have some fond memories.

One particular couple, The Clays, crack me up every time I think of them. They were both in their 80's the first time I came out to check on their farm dogs. The wife had grown up on the farm, was actually born in the house. We got there and did what we needed to do for the dogs and were wrapping things up to get to my next call, a euthanasia. Before we could leave though, the husband and wife decided we needed to take a tour of the house and all the out buildings. I got to see 80 years of items collected in dusty out buildings, pictures, antique furniture, old boating equipment. I got to hear stories associated with said items. Very long, informative stories.

While I love to chat it up with clients, I was getting anxious because of the euthanasia scheduled in less than an hour. It was at least a 30 minute drive. I don't like to make my clients wait- ever- especially a euthanasia appointment. I don't want them to have to stress any longer than necessary. When Mrs. Clay started to play the piano for me, I knew I had to step in and let them know I had to go on to my next appointment. Mr. Clay asked what the appointment was for. I told him a beloved older pet was to be put to sleep and I didn't want to make the owners wait. He said with laugh "Oh, let the dog live a little longer! Honey, play them a little Missouri Waltz!"

I politely listened and edged my way out of the house. Mr. Clay followed me outside and just as I was loading up my truck, he mentioned he had recently had surgery. Before I knew what was happening, he had flipped his overall clasps off and was standing in his yard in only his undershirt and underwear, overalls at his ankles. He just wanted me to take a second and look at his scar - on the inside of his thigh....

I can't even remember how I got out of there, I think I have blocked it out of my brain. I did make it to the euthanasia appointment on time.

The Clays were great clients from that time on. Their dogs passed away and they moved into an assisted living facility. Their old farm house has since been torn down and new houses replace it.

Every time I drive by that area, I hear the Missouri Waltz playing in my head.

I performed a STAT castration this week. A nice family had purchased two rabbits, and were told they were both the same gender. But—over the weekend a litter of baby bunnies mysteriously appeared in the cage. So I castrated Daddy, and hopefully we’ll be spaying Mommy soon.

It’s pretty common that we’ll see kittens, rabbits, guinea pigs, etc. that are supposed to be one gender but turn out to be the other. This leads to some embarrassing and amusing exam room moments. I have one patient, a 10-year-old neutered male cat named “Belle,” whose owners still refer to him as “her” because they were told that “she” was female as a kitten.

It’s rather harder to mistake a male dog for a female, but it happens. We recently saw a new puppy, a German shepherd named “Sarah.”Vet: “Um, Sarah’s a boy.”Client: “Really? The breeder said she was a girl.”Vet: “Yes, that’s his penis right here.”Client: “Oh, I wondered what that was.”

The moral of the story is: Gender should be verified by a professional.

Wednesday, January 25, 2012

Wow, just wow. Has anyone seen the pet cloning TV show yet? Sorry, but there are just so many issues with cloning. I had a cloned patient when I was in vet school. She, while a fascinating and fun creatures, was seriously messed up. She might have looked like the original, but her ability to fight off diseases was pretty much in the toilet.

So, other than this cloned patient in vet school, I remember one other cloning procedure when I was in vet school. As with all vet schools, we mostly saw cases that had been through the primary vet and sometimes a secondary specialty hospital. However, there were some clients that were such frequent flyers with a few animals, that they felt like they could just bring in any animal, totally circumventing the whole referral process. This story is about one such client.

Players:

Client: crazy horder with about 20 animals that had been seen at one time or another by *some* service at our teaching hospital.

Clinician: A dermatology resident (yes, most dermatologists do not need to take call for clients)

Students: Motley crew of 4th year students towards the end of a long night on ICU duty

Setting: Emergency Service approximately 11 PM on "not a special night."

Scene:

Dermatology resident: "I need a team to help me with a patient, the owner is almost here."

Students (imagine a Greek Chorus): "What is going on?" "What is the presentation?" "Who is this patient?" "Why is a dermatology resident at the hospital at 11 PM at night?"

Dermoid: "Patient is a 10 year old cocker. He has metastatic mast cell disease (cancer). And lymphoma (another cancer). And atopy (environmental allergies). And glaucoma. He is dying and the owner wants us to harvest tissues for cloning."

Students: "WTF??" "Are you kidding?" "Won't a clone have most of the same issues?" "Why is a dermatologist on call?"

Dermoid: "Yeah, I gave her my phone number after dealing with the skin issues from about 10 of her animals. She is a little special."

Students: "Gave her your phone number?" "WTF?" "She has how many animals?" "And this is a skin emergency, how???"

************************

Client shows up sobbing wildly: "Be sure to get part of the brain and a piece of the liver!!!"

Students: "I think he is dead." "Will this affect the cloning process?" "Will this affect my grade?" "WTF is a dermatology resident doing in the ICU at 11 PM doing a NECROPSY???"

Dermoid: "Ok, so he is dead. Just cut some pieces off of him and bag them. I've gotta go get some sleep. I have to be here at 8AM."

Anyone who deals with the public is going to accumulate stories about the memorable people with whom they’ve crossed paths. You’ve noticed this. Some of the people you meet will leave you smiling, and others are responsible for that spit drying on the inside of your car’s windshield after you have vented some of your frustration during your drive home at the end of the day. If you’ve explored this blog at all you no doubt recognize some of the people the veterinarians here are frustrated with. These individuals have likely ruined your day, too. I’m talking truly remarkable people here, the ones that years later still send a surge of acid up your throat when their memory somehow slides back into your consciousness.

I read once that our sense of smell is the best trigger for memory. And I’m sitting here at the computer reliving some of the worst days of my career, when the ignorance or irresponsibility of a client presented the very worst odors to a nose accustomed by this job to some pretty rank stench. If you are eating, or the kids are reading along with you, or you confess to being a tad faint of heart, I’d skip the rest of my story. For the brave who continue here, sorry about this…

Decades ago, when the options for fracture repair available to veterinarians were nowhere near as extensive as what we now enjoy, clients shied away from the better care every bit as often as they do now. Some couldn’t afford the best, and others couldn’t care. Ya grow accustomed to this in our line of work. This puppy should have had surgery on its busted rear leg, but his people were headed for Vegas for the weekend and they wouldn’t spare the money.

Our fall back option was a splint constructed from an aluminum rod bent to shape and the clever application of large volumes of tape to hold the leg steady within this support. These things worked well, but with a growing puppy we needed to check the splint weekly to assure that it wasn’t knocked askew by romping enthusiasm, or simply needed adjustment to account for growth. Eight weeks or so of this usually gave us an adequate fracture repair, and a pup who could then live a normal life. These folks missed the first recheck, and then the second. No one answered their phone. Time passed. No rechecks.

Four months later they showed up, without an appointment, to have the splint removed. I smelled them coming, long before they entered the exam room. The stench was remarkable, and maggots fell out of the splint when they lifted the crying pup onto the table. It was February, and even here that means winter. Those flies that lay their eggs on dead animals and thus yield ugly maggots had left by the end of October, but apparently not in that house.

The pup was in agony, but still sweet. Drugs lent him some peace while I cut off the splint. Much of the leg came with, rotting pieces falling off and stuck by the hair to the filthy old tape. Writhing gobs of maggots fed on this stew. Amazingly, the leg healed after this, and since I kept the gun locked up, the owners survived, too.

Few things smell worse than parvo. Picture an innocent young puppy, spewing sticky yellow slime from the front end and unworldly horrid bloody diarrhea out the other, and lying in the puddle, too weak to crawl out, for 6-8 days. Most will die without treatment, but many can survive with proper care. Hopefully, this is as close to parvo as you will ever go. But let me assure you that one puppy with parvo will stink up the entire hospital, and seven at one time will peel the paint.

Vaccines have been available since the early 80’s and the disease is utterly preventable. Only ignorance and irresponsibility on the part of too many owners allows it to hang around at all, and so it still kills puppies.

The young lady was nicely fitted out, all make up and perfume, provocative clothing, and that come hither smile as she began to negotiate with me over the cost of treating her sick puppy. I guess she was hoping for stupid. No doubt her ready availability had worked wonders in the past on men my age. I glanced at the medical chart and noticed that this was the third puppy with parvo she had presented to me in the last ten years. And she still had not vaccinated this puppy. Fortunately, the gun was locked up. I laid a short dissertation on her irresponsible head. She was not smiling as she left.

The animal control truck backed into a parking space next to my clinic. What manner of disaster was the officer bringing in this time? He headed for the box on the truck bed carrying the snare pole. Not a good start.

The mostly grown pitbull puppy was screaming in agony as he pulled it along with the pole. “Doc, ya gotta put this one down right away. Some kids set it on fire, and he’s all burnt all over. I can’t even touch em.”

Story was three or four “kids” had doused the pup with lighter fluid and then set him ablaze. The “kids” sped off leaving the pup running around in flames. The officer figured the pup wouldn’t fight in the ring, so they tried to kill him nasty-like as a lesson for their other dogs. And yeah, the “kids” who fight dogs are that stupid. Ask Michael Vick.

Third degree burns means burnt hair, charred tissue, blackened parts of dog falling off on the floor. Could not touch the dog anywhere without him screaming and fighting. We had to pin his frothing screaming head to the floor with the snare pole to get close enough to inject a hind leg with drugs potent enough to finally get near him to give the final injection that let him out of this life.

Could not get the dog’s screams out of my wretched brain for months. The smell I will leave to your imagination. I had impure thoughts about those “kids”. For them, I would have unlocked the gun.

Sorry about all this. But if any reader questions the motivation behind some of the less than perky descriptions of bad client behaviors in this blog, maybe this will help with understanding.

I reiterate to my clients over and over again (both in person and via my blog) that one of the most important parts of adopting any animal is starting a savings account for that pet. Putting aside even a few dollars a week into an account for pet health/pet emergencies is the best thing you can do for your companion.

Why? First, none of us can tell when an emergency with our pet will arise. You can take the best care possible of your pet, and they can still suffer illnesses such as urethral obstruction or GDV. Secondly, if a client couldn't afford something I recommended but told me that they could meet me halfway because they saved up for this sort of thing, I'd be much, much more likely to help them out with the bill somehow.

Case in point. I was recently presented with a laterally recumbent, seizuring, vomiting dog. Ellie was a 3 year old, female spayed Lab mix. She was allowed to roam free. The previous day, she'd been normal. This morning, the owners had found her practically non-responsive, seizuring and twitching in the back yard. They rushed her to us.

The exam fee for me to even do a physical exam on a patient is $92. These owners had nothing. Ellie was obviously in critical condition, so I examined her anyway. After listening to her history and examining her, I came to the conclusion that she was likely suffering antifreeze poisoning.

I went over this with the owners and discussed treatment options. They assured me that they had NO money. Nothing. Not even the examination fee. They applied for CareCredit and were declined. Then they just sat there and stared at me, waiting for me to offer options. I explained again that we did not bill. Even if we DID bill, Ellie was likely too far gone for the antifreeze antidote to work at this point.

Still, they sat. Then the husband said, "You know, I don't want to put my dog down for financial reasons. Can't you work with me?"

Why would *I* lend money to someone I don't know? First, it's not my clinic. I am an associate. Thus, if I extend credit to someone that I doubt will ever pay us a dime, I am essentially stealing from my employer. Secondly, if a person cannot get approved for a medical purposes credit card and cannot find one family member or friend to loan them money, why would I trust them and extend credit?

In the end, the owners allowed me to euthanize Ellie to stop her suffering. These clients made no effort to even meet me halfway - say coming up with the exam fee and $60 to confirm my diagnosis with a few simple lab tests. Had they made any effort at all, I could have done some simple, cheap things to make sure I was right (a urine sediment exam to look for a specific type of crystal seen with antifreeze poisoning, a blood gas to assess pH of the blood, anion gap, and electrolyte status). But they didn't. They expected it all for free.

When we went to load the body into the car, the owners pulled up to the curb in an almost brand new sports car (certainly FAR nicer than my 13 year old SUV) and unloaded several thousands of dollars worth of audio equipment from the trunk to make room for the body of their *beloved* dog.

If you want to get your vet to help you out, you have to meet us at least halfway.

Tuesday, January 24, 2012

As has been previously mentioned, veterinarians are people too (shocking, I know). However, much like young children who seem shocked and amazed when they find out that their teacher doesn't actually live at the school, so do the clients often seem, if not shocked, then at least surprised to see their veterinarian outside of the clinic, doing something as mundane as purchasing groceries, getting the car fixed, visiting the pediatrician's office, or even (gasp) standing in line at the post office.

That's cool. I mean, seeing as how I'm a person, I know how it can feel like a nice pleasant surprise to run into my physician, pediatrician, or clarinet teacher, or whatever other professional type person I've had a pleasant ongoing relationship with somewhere other than his or her office or school. You want to say hello, maybe crack a joke, share a smile - it's all good. Sometimes, though, these encounters go horribly wrong. Last week, I had one of those.

I was at a house of worship, speaking to the administrative office staff there at a time when no services were being held, but some educational classes for children were in session. One of the teachers was planning a teaching module about how helping animals is a charitable act, or something like that, and she had asked me to drop by. So I was standing there in the office chatting with this nice lady at the desk when another woman walked in, looking vaguely familiar. She said hello to the lady at the desk and then she did a double take at me and said "DOCTOR VBB! What are you doing here?"

I said "well, I'm here to meet Ms. Kidwrangler to go over a lesson plan, actually. How are you doing?" She said to me, "oh, it's so kind of you to ask, I'm doing just fine" and then leaned over the desk and said to the receptionist, "remember how I was so depressed after Dingo passed away? Well, Dr. VBB here is the one that killed him! Whattya know?"

Of course a whole bunch of people were walking into the office just at that time.

There was an awkward silence that seemed to last forever, before my client realized what she'd said, and cleared my name, explaining that she'd brought Dingo to see me for euthanasia, after a long illness during which I'd cared for him quite well.

I'm not sure any of those people will ever look me in the eye again, though.

Years ago when I was first out of school, I worked at a large mixed animal practice in a tiny town. The practice employed 5 veterinarians and a multitude of support staff. Needless to say, we saw a ton of patients.

One day, the front office put a call through from the police asking us about a patient. I told them that we could not release information with just a phone call. The policeman on the other end of the line got a little irate:

"I have bloody remains in box with your clinic's name on it. I need information on a patient named 'Baby Jones.'"

Well, that changed things a bit. The officer elaborated and it quickly became clear that, though a crime had been committed, it was not a capital crime.

An excavation company in town had large piles of dirt, top soil, mulch, and lime. They had seen someone driving around the piles and when they went out to check, the people were gone. However, in their wake, they left a humped up mound with cut flowers on top of it just next to the lime pile. When the worker uncovered the large cardboard box, he saw the words "Baby Jones" written on the top. Given the blood on the box, the flowers, and the writing on the box, he immediately called the police.

The first policeman on the scene arrived and opened the box. The first thing he noted was a large amount of blood and a body that had been cut open. He freaked out and got a little sick. The next police officer had a little bit of forewarning so when he looked, he saw the animal fur coat, making the assumption that someone buried a mutilated dead infant a non-issue.

As it turns out, the body in question belonged to a patient of the clinic that had died and the owners requested a necropsy (our word for autopsy). So, one of our fellow vets had opened up the animal to see if they could find a cause of death. When he was done, he wrapped up the body and placed in a box that had been used to ship supplies to the clinic. Hence, the police tracking the body back to our clinic.

I have a heartbreaking story to tell. One that does beg to differ with those who accuse us of doing things only for the money.

I have these wonderful clients who love their dog, Mr. Sweets. Mr. Sweets does not hurt for food and is overweight. I used to harp on them about his weight, until one day - only a few visits after I'd first met them - the owner (Mr. Z) pulled me aside and informed me that his wife (Mrs. Z) had advanced Alzheimers, can't remember when she feeds Mr. Sweets, and therefore the dog will not be able to lose weight. He also informed me that "that damned dog keeps her alive" and that anything else I can do to work with him would be greatly appreciated.

Okay. Totally new rules to this game, I can see.

So Mr. Sweets secretly takes Slentrol, a drug that can help dogs lose weight. It doesn't do much other than keep him from being a total ottoman, and it's something that Mr. Z can give in secret without Mrs. Z finding out.

Then I started noticing how often they were coming to see me - nearly every day some weeks. So again Mr. Z and I had a discussion. I told him I didn't feel right about charging them for exams every day when there is never anything wrong with Mr. Sweets. He told me that he knew there was nothing wrong with "that damned dog" but that every time he sneezes, Mrs. Z (with advanced alzheimers) goes into a panic and demands that he go to the vet. Who happens to be me.

Okay. So now I really understand the game.

I think about it, and I call Mr. Z and tell him this: "Mr. Z, you are a wonderful person and I don't know how you make it through your day. Your wife of 50 years doesn't know who you are most of the time yet you take exquisite care of her and her dog every single day. I saw you at the grocery store on Sunday and you were buying a whole bunch of beer, I presume for yourself. So I'm gonna offer you something that I hope helps, and hopefully will make your life a little easier. You deserve a break."

I told Mr. Z that he is to bring Mrs. Z and Mr. Sweets down as many times as he wants, to see me. I will do a full exam on Mr. Sweets in front of Mrs. Z so she will know he is OK. The only condition to be met is that he comes during the hours when I am not slammed with appts - anytime at all between noon and 2pm.

And I will not charge him a dime. Ever.

He was so touched that he cried, and of course we saw Mr. Sweets a LOT. The truth is that Mr. Sweets could come see me at noon, and then go home, sneeze, and then be back in an hour, because Mrs. Z wouldn't remember that he just saw me at noon. But this made her happy and gave Mr. Z some peace of mind that his beloved wife of 50 years was up and about and still functional to some degree.

This went on for about 6 months. Then we recently learned that Mrs. Z is now in the hospital and not doing well. Mr. Z is still by her side, not leaving the hospital. It is the real life version of The Notebook.

I just received the most awesome job application, and here´s why it rocks:

A) Puts in cover letter that she is looking for a certified Tech position, when she isn´t a certified Tech.

B) Misspells her own name and lists her DOB as 1083.

C) Is certified in animal first aid, when no such certification even exists. Those bullet points about EKG and defibrilation are a huge bonus.

D) Is a certified homeopath (no certification exists) that has a mobile practice in my area. Now thats´s what every practice needs, somebody adverstising their private business to your client base.

E) States that she will be a great asset in helping diagnose patients and developing treatment plans. Hmm.. I thought that was my job. Maybe she can do this between defibing patients and brewing homepathic remdies?

Monday, January 23, 2012

Client with two English Bulldogs who were constantly in the clinic for one reason or another:
Client: "What would you do if I told you I was thinking of getting a third Bulldog?"
Dr. Snarky: "I'd go shopping for a boat."

Client whose Golden Retriever presented for staph pyoderma of the dorsal midline:
Client: "I'm pretty sure it's fungal".
Dr. Snarky: "It's not fungal."
Client: "Well, a while ago I had a pretty bad case of jock itch. Could I have passed it to the dog?"
Dr. Snarky: "Not unless you're in the habit of riding him around the house bareback and naked".

Client: "My dog needs one of those bordello shots."
Dr. Snarky: "You take your dog with you to the whorehouse?"

Client of ancient Dachshund with generalized paresis that knuckled over on his right front paw when walking (client was a retired circuit court judge of very sober demeanor):
Client (proudly): "I figured out the perfect way to protect his paw."
Dr. Snarky: "Do tell."
Client: "I went to the drug store and bought a single condom. It's waterproof, and protects the paw perfectly!"
Dr. Snarky: "I bet they're impressed when you ask for the one foot size."
(No reaction from da judge. Not a smile, nothing - just awkward silence. This same client came in for an appointment a few years later sporting a t-shirt that had a picture of a Dachshund, and the logo "Beware of my weiner". I'm certain the double-entendre sailed right over his head. I happily imagined him wearing it to church).

Things

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